Plasma concentrations of monoethylglycinexylidide during and after breast augmentation.

MEGX (monoethylglycinexylidide) is the main metabolite of lidocaine and is 83 percent as potent as an antiarrhythmic drug and with the same toxicity as lidocaine. In this study, plasma levels of MEGX were measured in 10 other wise healthy women during and after breast augmentation. A total dose of 825 to 1,280 mg of lidocaine of 0.2% and 0.5% lidocaine with epinephrine corresponding to 16.3 to 21.8 mg/kg (mean, 18.2 mg/kg) was injected in the spatium between the pectoralis muscle and the mammary gland. The peak plasma concentrations of MEGX varied between 0.40 and 0.99 microg/ml (mean, 0.49 microg/ml) and occurred between 8 and 12 hours (mean, 9.1 hours), postoperatively. In three patients, the concentration of MEGX was still increasing after 12 hours. In comparison, the peak plasma concentrations of lidocaine varied between 0.96 and 3.12 microg/ml (mean, 1.49 microg/ml) and occurred between 4 and 12 hours (mean, 7.3 hours) after the end of the injection. The peak lidocaine + MEGX concentrations varied between 1.45 and 3.58 microg/ml (mean, 2.02 microg/ml) and occurred between 5 and 12 hours (mean, 8.5 hours), postoperatively. These data suggest that MEGX might contribute to lidocaine toxicity when high doses of lidocaine are injected. The substantial interindividual variation strongly indicates that recommendations about maximum safe doses of lidocaine should be made with caution.

Absorption of effervescent paracetamol tablets relative to ordinary paracetamol tablets in healthy volunteers.

OBJECTIVES: The aim of this study was to compare the rate of absorption between ordinary paracetamol tablets and effervescent paracetamol tablets. METHODS: Twenty healthy volunteers participated in an open randomised crossover study and were given a 1000-mg dose of either ordinary paracetamol tablets (2 x 500 mg Panodil tablets, SmithKline Beecham) or effervescent paracetamol tablets (2 x 500 mg Pinex Brusetablett, Alpharma AS) with a 3-week washout period in between. Blood samples were collected for 3 h. Maximum serum concentration (Cmax) and the time to maximum serum concentration (tmax) were recorded and the area under the concentration versus time curve (AUC) was calculated. RESULTS: The mean tmax was significantly shorter when paracetamol effervescent tablets were taken (27 min) rather than ordinary paracetamol tablets (45 min) (P = 0.004). There was no significant difference between the mean Cmax of 143 micromol/l with effervescent tablets and that of 131 micromol/l with ordinary tablets. The mean AUC(0-3 h) was significantly higher with paracetamol effervescent tablets (223.8 micromol x h x l(-1)) than with ordinary tablets (198.2 micromol x h x l(-1); P = 0.003). After 15 min, 17 (85%) subjects in the effervescent group had a serum concentration of 70 micromol/l (lower therapeutic serum concentration) or higher relative to only 2 (10%) subjects in the ordinary tablet group (P = 0.001). CONCLUSION: Paracetamol effervescent tablets are absorbed significantly faster than ordinary paracetamol. Thus, effervescent tablets might offer significantly faster pain relief when paracetamol is used.

Plasma concentrations of lidocaine and alpha1-acid glycoprotein during and after breast augmentation.

Plasma levels of lidocaine and the main binding proteins of lidocaine in plasma alpha1-acid glycoprotein (AAG) and albumin were measured in 10 otherwise healthy women during and after breast augmentation. A total dose of 825 to 1280 mg of 0.2% and 0.5% lidocaine with epinephrine corresponding to 16.3 to 21.8 mg/kg (mean 18.2 mg/kg) was injected in the spatium between the pectoralis muscle and the mammary gland. The peak plasma concentrations of lidocaine varied between 0.96 and 3.12 microg/ml (mean 1.49 microg/ml) and occurred between 4 and 12 hours (mean 7.3 hours) postoperatively. The plasma concentration of AAG varied between 0.42 and 1.73 g/liter (mean 0.49 g/liter, normal range 0.54 to 1.17 g/liter). There was a significant correlation between the plasma concentration of AAG and lidocaine. The mean concentration of albumin was 37.2 g/liter, ranging from 33 to 42 g/liter (normal range 35 to 50 g/liter). No patient showed signs of lidocaine toxicity. These data indicate that a dose of 20 mg/kg of lidocaine with epinephrine probably is safe in breast augmentation when the drug is administrated as described in this study. There are significant individual differences in the plasma concentration curves between patients, partly explained by different concentrations of AAG. Further studies with a larger number of patients are needed to establish definitive recommendations of safe maximal doses.

[Magnetic tomography in diagnosis of breast implant rupture]. / Magnettomografi i påvisningen av brystimplantatruptur.

At least 20,000 Norwegian women have silicone breast implants, either for breast augmentation or for reconstruction. One of the complications associated with breast implants is rupture of the implants. Magnetic resonance imaging (MRI) has been shown to be the most accurate imaging modality for evaluating the integrity of breast implants. Recognition of the different types of implants and the appearance of normal implants on MRI is very important for distinguishing these from intracapsular and extracapsular ruptures. Examples are shown of MRI findings in normal and ruptured implants.

Acute erosions of the gastric mucosa in burned rats: effect of sucralfate.

The effect of intragastric sucralfate on development of gastric erosions in burns was studied in 20 rats anaesthetised with midazolam/fentanyl/fluanisone. Gastric blood flow was measured by radioactive microspheres immediately before, and 20, 40, and 120 minutes after the rats had been burned. Significantly fewer erosions were found in the 10 rats treated with sucralfate (less than 2% of the gastric mucosal surface was affected) compared with the controls (16% of the mucosa affected). There was no difference in the rate of gastric blood flow in any part of the stomach between the rats treated with sucralfate and the controls. We conclude that sucralfate is effective in preventing gastric erosions in burned rats, but that other mechanisms of action than increase gastric blood flow are responsible for its protective effect.

Modest release of adipsin/factor D by liposuction when using the superwet or tumescent technique.

Human adipsin is recognized to be identical to factor D, which plays an important role in activation of the alternative complement pathway. Since adipsin/factor D is present in high amounts in adipose tissue, liposuction theoretically could result in an increased release of this serine protease into the bloodstream. In the present study, adipsin/factor D was measured in 22 patients undergoing syringe-assisted liposuction using the superwet or tumescent technique. Despite a relatively high mean aspirate volume (2648 ml), only a very modest increase in adipsin/factor D concentration was found during liposuction. All values before, during, and after liposuction were within the range found in healthy blood donors. Furthermore, there was no correlation between adipsin/factor D values and C3 activation products. We conclude that liposuction with the present techniques results in a very modest release of adipsin/factor D that is not associated with increased complement activation.

Suction-assisted lipectomy does not increase the risk of random flap necrosis in a randomized study in pigs.

Thirty-two dorsally based random flaps were raised in eight Yorkshire pigs (26-31 kg) after infiltration with 200 mL of dilute lidocaine (0.1%) with epinephrine (1:1,000,000) into each flap. Prior to elevation 16 of the flaps were treated with syringe-assisted liposuction, while the remaining flaps served as controls. One week postoperatively the viability of the flaps was assessed with computer-assisted planimetry of the necrotic area and by measurement of capillary blood flow using radioactive microspheres. The mean area of necrosis was nearly identical in the flaps treated with liposuction and in the control flaps, and there was no statistically significant difference in blood flow between the groups. The results show that liposuction performed with the "super-wet" or "tumescent" technique can be done prior to elevation of flaps in pigs without increasing the risk of flap necrosis.

A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgery.

Over a 9-month period from September of 1991 to May of 1992, 339 patients were included in a randomized, double-blind, placebo-controlled study using azithromycin as the prophylactic agent to determine whether it effects a clinically meaningful reduction in postoperative surgical infections in plastic surgery. Azithromycin was given as prophylaxis in 171 patients and placebo in 168 patients. The study medication was a single oral dose taken at 8 P.M. the day before surgery. The patients were followed up for a minimum of 4 weeks after surgery. The patients who received wound infection prophylaxis had 5.1 percent infections compared with 20.5 percent in the placebo group (p = 0.00009). Eighty percent of all wound infections were first seen after discharge, explaining why plastic surgeons might overlook their infectious complications. There was a significant reduction in postoperative complications (p = 0.04) and in the additional use of antibiotics postoperatively (p = 0.007) in the prophylaxis group. Subgroup analysis showed a significant reduction in surgical infections in breast surgery (p < 0.05) and reconstructive surgery with flaps (p < 0.05). No effect of the prophylactic regime was demonstrated in patients undergoing secondary surgery for cleft lip and palate disease.

Effect of syringe-assisted liposuction on activation of cascade systems and circulating cells when using the superwet or tumescent technique.

Although liposuction is considered to be a relatively safe procedure, several deaths and nonfatal serious complications such as sepsis, toxic shock syndrome, thromboembolic disease, fat emboli, and adult respiratory distress syndrome have been reported. In the present study, we have investigated a wide variety of components belonging to the coagulation, fibrinolytic, plasma kallikrein-kinin, and complement systems in 22 patients undergoing syringe-assisted liposuction using the superwet or tumescent technique. In spite of a relatively high mean aspirate volume (2,648 ml), only small changes over time well within the normal range were found for the different parameters. In nine randomly selected patients, we also measured interleukin 6 and tumor necrosis factor-alpha. The size of the interleukin-6 peaks was found to be of the same order of magnitude as those measured in patients undergoing hernia repair or percutaneous cholecystectomy but lower than those in patients undergoing open cholecystectomy, breast reduction, or breast reconstruction. Tumor necrosis factor-alpha was not detected in any sample in any of the patients. We conclude that syringe-assisted liposuction with the present aspirate volumes using the superwet or tumescent technique represents a small to moderate surgical trauma without clinical significant activation of the cascade systems.

A prospective, randomized surveillance study of postoperative wound infections after plastic surgery: a study of incidence and surveillance methods.

In a postoperative wound infection study in plastic surgery, 315 patients were randomized to either outpatient wound control after 30 days (group I) or self-control by questionnaire (group II). We present a new definition of wound infection based on physiologic wound healing. The surveillance of postoperative wound infection showed follow-up rates of 95 and 68 percent and infection rates of 16.3 and 17.1 percent for groups I and II, respectively. Of the 43 patients (16.7 percent) with postoperative wound infections, 31 (72 percent) were diagnosed after leaving the hospital, and only 12 (28 percent) were diagnosed during hospital stay. The monthly wound infection rate declined from 23.5 percent when the registration started to 12.2 percent at the end of the surveillance. The wound infection rate nearly tripled when duration of surgery was more than 120 minutes compared with less than 60 minutes. Postoperative wound infection was significantly related to preoperative contamination class, with an increase from 10.2 percent wound infections in class "clean" to 37.5 percent in class "dirty." We conclude that postoperative wound infection also crops up in the plastic surgical department, and this situation has not, to date, been documented sufficiently. A simple questionnaire gives a useful survey of postoperative wound infections. An active follow-up for at least 30 days is essential to register the rate of surgical infections.

Blood loss during suction-assisted lipectomy with large volumes of dilute adrenaline.

The amount of blood lost during liposuction with the "dry" or classic "wet" techniques has been a cause for concern. In the present study 26 consecutive patients who underwent syringe-assisted liposuction with the "superwet" or "tumescent" technique had their blood loss recorded prospectively. The mean (SD) volume aspirated was 2448 (1368) ml and the mean (SD) drop in haemoglobin concentration was 11 (7) g/l. The haemoglobin concentration was measured in both the fluid and the fat fraction of the aspirate, and the mean (SD) amount of whole blood was 16.5 (9.3) ml/litre of aspirate. The present study shows that blood loss is considerably reduced when the "super-wet" or "tumescent" technique is used, compared with the reported amount lost by authors who used the "dry" or classic "wet" techniques.

Troublesome colostomies and urinary stomas treated with suction-assisted lipectomy.

OBJECTIVE: To investigate the effectiveness of liposuction as treatment in troublesome colostomies and urinary stomas in selected patients. DESIGN: Open clinical study. SETTING: University hospital, Norway. SUBJECTS: 8 consecutive patients with colostomies (n = 2) or urinary stomas (n = 6) who required treatment with liposuction above or around the stoma, mainly for leakage. INTERVENTIONS: Syringe-assisted liposuction under local anaesthesia. MAIN OUTCOME MEASURES: Change in stoma function, particularly reduction in the incidence of leakage, and by the patients' satisfaction graded according to a four point scale. RESULTS: All patients noted considerable improvements in stoma function, or abdominal contour, or both. CONCLUSION: Troublesome colostomies and urinary stomas can in selected patients be successfully treated with liposuction above or around the stoma.

Syringe-assisted microliposuction for cervical rejuvenation. A five year experience.

During a five year period, 71 patients (age range 24-72 years) underwent syringe-assisted liposuction of the neck as the only operation for facial rejuvenation. The patients were seen after one week and three months, and 66 patients were re-examined 5-58 months (mean 31) postoperatively. There were no complications except for slight skin laxity (n = 10), transient hypoaesthesia, and temporary subcutaneous scarring (nodules). In some patients improvement occurred more than 12 months post-operatively. The patients evaluated the result according to a four grade scale; very satisfied (n = 41), satisfied (n = 21), less satisfied (n = 4), and dissatisfied (n = 1). All patients except one would recommend the procedure to other patients with similar problems. We conclude that syringe-assisted liposuction of the neck is a simple, safe, and rewarding procedure even in many elderly patients.

Effect of large-volume liposuction on sex hormones and glucose- and lipid metabolism in females.

Nine consecutive patients who underwent syringe-assisted liposuction with a mean aspirate volume of 3633 mL (range: 1800-5500) had their lipids, lipoproteins, and sex hormones measured pre- and postoperatively. Seven of the patients also underwent an oral glucose tolerance test with measurements of insulin and C-peptide. The major finding was a significant increase in HDL cholesterol and apolipoprotein A1, while there was no significant change in sex hormones or glucose levels 9-12 months after the liposuction procedure. The results indicate that large-volume liposuction might decrease the risk of cardiovascular disease in these patients.

Surgical treatment of gynaecomastia. Five years' experience with liposuction.

Since liposuction became part of our surgical regimen in 1988, we have operated on 67 patients for gynaecomastia during the five year period 1988-1992. Sixty two of the patients were seen at an extra follow up 4-59 months (means 29 months) postoperatively. Compared to studies that did not include liposuction as part of the operation, we found a lower incidence of postoperative complications and a higher degree of patient satisfaction. Preoperative distinction between adipose and glandular tissue is difficult, and we therefore consider that liposuction should be used during the first part of the operation in nearly all cases of gynaecomastia. Regardless the amount of fat, tunnelling and suction are beneficial, because they help to refine the peripheral contour and define the glandular tissue. Liposuction seems to help the skin to contract, and skin resections are rarely indicated.

Plasma lidocaine levels during suction-assisted lipectomy using large doses of dilute lidocaine with epinephrine.

Liposuction, like many other plastic surgical procedures, is often performed under local anesthesia. Drug toxicity is the most serious complication and the factor that limits the use of this form of anesthesia. Toxic effects are related to the peak concentration in plasma and depend on the type of local anesthetic, the drug concentration, total dose, site of injection, injection speed, and whether vasoconstrictors are used or not. This study evaluates the use of large volumes of subcutaneously injected 0.1% lidocaine with epinephrine 1:1,000,000 as the local anesthetic procedure in 12 patients undergoing suction-assisted lipectomy of the abdomen, flanks, and/or lower extremities. A total dose of 1260 to 2880 mg lidocaine corresponding to 10.5 to 34.4 mg/kg was administered with an injection speed of 60 to 78 ml/min. The peak concentration of lidocaine varied between 0.9 and 3.6 micrograms/ml and occurred between 6 and 12 hours postoperatively. For the given dose range, a linear correlation (r = 0.83) was found between the total dose of lidocaine and the peak concentration in plasma. A dose increase of 1 mg/kg raised the peak concentration approximately 0.1 microgram/ml. Our data clearly demonstrate that when using pH-adjusted 0.1% lidocaine with epinephrine subcutaneously for suction-assisted lipectomy, lidocaine can be administrated safely in significantly higher doses than recommended. When such high doses are used, the patient probably should be observed for at least 18 hours postoperatively.

Alkalisation of lignocaine-adrenaline reduces the amount of pain during subcutaneous injection of local anaesthetic.

A double blind, randomised controlled trial was performed to compare the amount of pain experienced after subcutaneous infiltration of lignocaine with adrenaline, and the same anaesthetic buffered to pH 7.1-7.3, in patients undergoing liposuction (n = 8), blepharoplasty (n = 7), mammaplasty (n = 6), and in volunteers (n = 10). A linear analogue pain scale was used to access pain. In all four groups the buffered solution caused significantly less pain (p < 0.001 except for mammaplasty--p = 0.02).

Blood loss during liposuction using the tumescent technique.

Blood loss during liposuction has been a concern when more than 1500 mL of material are removed during one session. Several authors have claimed that blood loss is dramatically reduced when the targeted area is infiltrated with large amounts of dilute lidocaine with epinephrine ("tumescent" or "superwet" technique). Using this technique, 25 consecutive cases in which the liposuction aspirate was expected to be 1000 mL or more were investigated with pre- and postoperative measurements of hemoglobin. In addition, hemoglobin was also measured in the fluid fraction of the aspirate. The mean +/- SD aspirated volume was 1658 +/- 518 mL and the mean +/- SD fall in postoperative hemoglobin was 0.7 +/- 0.6 g/100 mL (5.4% +/- 4.9%). The mean amount of blood per liter of aspirate was calculated to be 10.5 +/- 5.2 mL. These results clearly demonstrate that the blood loss when using the tumescent or superwet technique is dramatically reduced compared with the dry or classical "wet" technique.

Diabetic lipohypertrophy treated with suction-assisted lipectomy.

OBJECTIVES: To investigate the effectiveness of liposuction as treatment for lipohypertrophy in insulin-treated diabetic patients. DESIGN: Open clinical study. SETTING: Norwegian National Hospital, Oslo. SUBJECTS: Five consecutive diabetic patients operated on for insulin-induced lipohypertrophy. INTERVENTIONS: Syringe-assisted liposuction under local anaesthesia. MAIN OUTCOME MEASURES: Change in contours assessed by pre- and postoperative photographs, and by the patients' and surgeon's evaluations according to a four-point graded scale. RESULTS: Good or excellent results were obtained in all patients. Small surface irregularities were seen in two patients who had large volumes of fat removed from the proximal anterior thighs. Apart from this no side-effects or complications occurred. CONCLUSIONS: Insulin-induced lipohypertrophy ('insulin tumours') can be treated successfully with liposuction.